Posterior Vaginal Fornix Research Articles

Rectum separation in patients with cervical cancer for treatment planning in primary chemo-radiation

PurposeTo proof feasibility of hydrogel application in patients with advanced cervical cancer undergoing chemo-radiation in order to reduce rectal toxicity from external beam radiation as well as brachytherapy.Material and methodsUnder transrectal sonographic guidance five patients with proven cervical cancer underwent hydro gel (20 cc) instillation into the tip of rectovaginal septum adherent to posterior part of the visible cervical tumor. Five days after this procedure all patients underwent T2 weighted transversal and sagittal MRI for brachytherapy planning. MRI protocol included T2 weighted fast spin echo (FSE) imaging in sagittal, coronal and para-axial orientation using an 1.5 Tesla MRI. Separation of anterior rectal wall and cervix was documented.ResultsHydrogel application was uneventful in all patients and no toxicity was reported. Separation ranged from 7 to 26 mm in width (median 10 mm). The length of the separation varied between 18 and 38 mm (median 32 mm). In all patients displacement was seen in the posterior vaginal fornix, and/or at the deepest part of uterine cervix depending on the extension of the cul-de-sac in correlation to the posterior wall of the uterus. In patients with bulky tumor and/or deep (vaginal) extend of peritoneal cavity tumour was seen mainly cranial from the rectovaginal space and therefore above the hydrogeI application. Only in the extra-peritoneal (lower) part of the cervix a good separation could be achieved between the rectum and cervix.ConclusionHydrgel instillation in patients with cervial cancer undergoing chemoradiation is safe and feasible. Because of the loose tissue of the cul-de-sac and its intra- and extraperitoneal part, hydrogel instillation of 20 cc did not result in a sufficient separation of the cervix from anterior wall.

Pure transvaginal laparoscopic appendectomy

Natural orifice transluminal endoscopic surgery has been at the forefront of minimally invasive surgery. Benefits include no visible scars, less pain, and shorter recovery time. We describe a video of a 37-year-old female who underwent a pure transvaginal appendectomy (TVA) for acute appendicitis. This is 1 of 18 successfully performed TVAs at Yale-New Haven Hospital. Appropriate Institutional Review Board was obtained preoperatively. The patient was positioned in steep Trendelenburg and then a weighted speculum was introduced into the vagina allowing exposure of the posterior vaginal fornix. The cervix was grasped with a single-toothed tenaculum on the posterior cervical lip and the posterior vaginal fornix was visualized. Access to the peritoneum was achieved by electrocautery and then sharp dissection. A SILS™ port (Covidien, Mansfield, MA, USA) was introduced and pneumoperitoneum up to 15 mmHg was achieved. Two 5-mm trocars and one 12-mm trocar were used. A 5-mm 30° angled endoscope, a flexible reticulating endograsper, and straight standard instruments were used. The identified appendix was dissected and a stapler was used to divide the mesoappendix from the appendix. Following confirmation of good hemostasis and no spillage of bowel contents, the appendix was removed from the abdomen within a retrieval bag and the culdotomy was closed with a running absorbable suture. The patient tolerated the 27 min procedure well and was discharged home in good condition on postoperative day 1.

The practicability and surgeons’ subjective experiences with vaginal danazol before an operative hysteroscopy

This randomized, double blind, placebo-controlled study compared the usefulness of danazol 400mg vaginally versus 600mg orally in women as a preoperative preparation for hysteroscopic surgery.Ninety-one fertile women were randomly allocated to Group A (46 patients received 400mg of danazol placed into the posterior vaginal fornix and three oral tablets of commercially available folic acid as a placebo), and Group B [45 women treated with 600mg of danazol orally (200mg three times daily) and two vaginal tablets of Lactobacillus rhamnosus as a placebo]. The patients underwent an operative hysteroscopy, transvaginal sonography, blood tests, and a histological assay. A visual analog scale (VAS) score to compute the degree of the surgeon’s satisfaction was used. The outcome measures were as follows: an evaluation of the changes in the endometrial thickness, the prevalence of endometrial atrophy, changes in the blood tests, any collateral effects, the degree of difficulty and view, the duration of the surgical procedure, any complications during the operative hysteroscopy and associated side effects, and the surgeon’s satisfaction with the endometrial preparation.The vaginal administration route was associated with a more pronounced effect on the endometrial thickness. Significantly more patients receiving vaginal danazol (45/46) had a hypotrophic endometrium than those receiving oral danazol (37/45, P<0.01). In addition, the patients receiving danazol vaginally had a shorter operating time, lower infusion volume, fewer side effects, and a higher surgeon satisfaction.Vaginal danazol adequately prepares the endometrium for an operative hysteroscopy by thinning the endometrium effectively with few side effects and little impact on the metabolic parameters.

Practicability of vaginal washing fluid creatinine level in detecting premature rupture of membranes

The purpose of this study was to evaluate the reliability of vaginal washing fluid creatinine level for the diagnosis of premature rupture of membranes (PROM). A prospective diagnostic study performed in Shahid Sedoughi Hospital on 160 pregnant women (30 definite PROM, 30 no PROM and 100 suspected PROM) at 28-40 weeks of gestation. The vagina was washed by injection with a syringe filled with 3 ml of saline solution, and the washing fluid was collected from the posterior vaginal fornix and send to laboratory. Creatinine values in vaginal washing were measured and compared. The mean vaginal fluid creatinine levels in definite PROM group, suspected PROM and no PROM were 0.40 ± 0.20, 0.16 ± 0.04 and 0.08 ± 0.01 mg/dl, respectively, where the difference was statistically significant (P = 0.001). The sensitivity, specificity, positive and negative predictivity values and accuracy were 98.7, 100, 100, 98.8 and 87.1%, respectively, in detecting PROM by evaluation of vaginal fluid creatinine concentration with cut-off value of 0.14 mg/dl. This study showed that creatinine determination in vaginal washing fluid is a useful marker for PROM diagnosis. It is a reliable, simple, cheap and rapid test.

HMGA gene rearrangement is a recurrent somatic alteration in polypoid endometriosis

The pathogenesis of endometriosis is unclear, and several genetic, endocrine, immune, and environmental agents have been evaluated with no putative causative factors identified. Here, we show somatic genetic alterations involving HMGA1 (6p21) and HMGA2 (12q15) in 3 cases of polypoid endometriosis. The lesions involved the small bowel mesentery and perirectal soft tissue in 1 case and the posterior vaginal fornix and sigmoid colon serosa in 2 other cases, respectively. All had a polypoid configuration with cystically dilated irregular glands and fibrotic stroma, containing thick-walled vessels. Conventional cytogenetic analysis of 1 case showed 46,XX,t(5;12)(q13;q15) in all metaphases. Fluorescence in situ hybridization studies confirmed the balanced rearrangement of HMGA2. HMGA1 rearrangements were present in 2 additional cases. Rearrangements were exclusively found in the stromal component but not in the glandular component. These findings suggest that HMGA rearrangements likely contribute to the pathogenesis of endometriosis. However, additional studies are needed to better define the biologic role of this genetic alteration.

Sexual injuries during consensual sexual activity

The aim of this study was to retrospectively evaluate sexual injury treated in our clinic. We evaluated the results of 31 patients (17 males, 14 females; mean age 31,97±11,64; range 18 to 60 years) with sexual injury during consensual sexual activity, who presented to the emergency department between January 2004 and December 2010. Patients' age, etiology of injury, time passed since trauma, physical/operative examination results, type of treatment, duration of hospitalization, and postoperative complications were investigated. Sexual injury occurred in women as vaginal laceration and in man as penile fracture. All of the cases were treated with early surgical repair. Vaginal injuries were formed in virginal girls during the first sexual intercourse. Cases usually complained of vaginal pain and then bleeding during sexual activity. The commonest site of injury was the posterior vaginal fornix. Etiology of penile fracture was sexual intercourse and masturbation. Sudden pain in the penis, edema, color change, and sudden detumescence were the main complaints. Eleven patients had right, 5 had left and 1 had bilateral tunical ruptures, with defects of 0.5-3 cm in length. The patient with bilateral injury had accompanying incomplete urethral rupture. Sexual injury can be diagnosed effectively based on history and physical examination, and may be treated successfully with early surgical procedure.

Determining the Ease of Cervical Dilation in Patients Given Evening Primrose Oil (Eveprim®) Intravaginally before Hysteroscopy in Postmenopausal and Nulliparous, Premenopausal Women Ages 37-77 Years Old: A Pilot Study

The primary objective is to determine the ease of cervical dilation to 7 mm to allow diagnostic hysteroscopy in postmenopausal and nulliparous, premenopausal women after intravaginal administration of evening primrose oil (Eveprim®). The secondary objectives are to determine any cervicovaginal complications and adverse effects related to the intravaginal use of evening primrose oil. Descriptive (Pilot). Tertiary hospital. Six(6) postmenopausal and two (2) nulligravid premenopausal patients admitted at St. Luke's Medical Center, Q.C. with an intrauterine pathology (endometrial polyps, or other endometrial pathology) detected on transvaginal ultrasonography for hysteroscopy. Two softgels (1000 mg each) of evening primrose oil were placed into the posterior vaginal fornix four to six (4-6) hours before hysteroscopy. Preoperative cervical dilation (in mm) after evening primrose oil administration was measured using Hegars dilators in an advancing fashion beginning with 4 mm size until the endpoint 7 mm size. The ease of cervical dilation to reach 7 mm was determined using Likert scale. Patients were assessed for any adverse reactions and uterine cervico-vaginal complications. All patients given evening primrose oil achieved the cervical dilation of 7 mm with ease. Based on a Likert scale, 7 out of 8 patients were assessed to be easy while one was found to be somewhat easy. No adverse reactions and uterine cervico-vaginal complications were reported. Ease of cervical dilatation was observed in all patients given intravaginal evening primrose oil 4 to 6 hours before diagnostic hysteroscopy (7 mm diameter). No cervico-uterine complications and adverse effects were noted.

Diode Laser Laparoscopic Excision of Rectovaginal Deep Endometriotic Lesion with Shaving Technique

Posterior vaginal fornix lesion is the most common type of deep endometriotic lesion. This video is intended to demonstrate the availability of a diode laser system for the shaving technique of laparoscopic excision of the deep endometriotic rectovaginal lesion. We introduce two cases of endometriosis patients presenting with symptom of severe dysmenorrhea and bluish lesions protruding into the posterior vaginal fornix. On proper preoperative evaluation deep endometriotic rectovaginal nodule was identified at both cases. There was no rectal mucosal involvement. Surgical techniques include seperation of the anterior rectum from the posterior vagina and excision of the endometriosis in that area. Careful dissection is carried out using a diode laser system. Total procedure time was 120 and 90 minutes respectively. The patients were discharged on the third postoperative day without any complications. The shaving surgical approach with a diode laser system leads to a safe and effective laparoscopic dissection of deep endometriotic lesions.

OC11.04: Office sonovaginography: redefining the concept of a normal pelvis on transvaginal ultrasound in women with suspected endometriosis

POSTERIOR VAGINAL FORNIX Sensitivity Specificity LR+ Total accuracy 57.9% 88.6% 5.1 77.8% 57.9% 91.4% 6.7 79.63% 94.7% 97.1% 33.2 96.3% 73.1% 94.3% 12.9 87.1% UTERO-SACRAL LIGAMENTS Sensitivity Specificity LR+ Total accuracy 55.6% 80% 2.8 75.9% 55.6% 95.6% 12.5 88.8% 88.9% 95.6% 20 94.5% 66.7% 95.6% 15 94.7% RECTO-VAGINAL SEPTUM Sensitivity Specificity LR+ Total accuracy 58.3% 83.3% 1.7 66.7% 63.9% 88.9% 5.7 72.2% 80.6% 100% Infinity 87% 83.3% 77.8 6 81.5%

Deeply infiltrating endometriosis: Evaluation of retro-cervical space on MRI after vaginal opacification

ObjectivesTo prospectively investigate diagnostic value and tolerability of MRI after intra-vaginal gel opacification for diagnosis and preoperative assessment of deeply infiltrating endometriosis. MethodsSixty-three women with clinical suspicion of deeply infiltrating endometriosis were previously examined with trans-vaginal ultrasonography and then with MRI pre and post administration of vaginal gel. We evaluated the tolerability of this procedure with a scoring scale from 0 to 3. We also assessed with a score from 1 to 4 the visibility of four regions: Douglas-pouch, utero-sacral-ligaments, posterior-vaginal-fornix and recto-vaginal-septum. All patients underwent laparoscopic surgery after MRI. ResultsFive patients considered procedure intolerable. Visibility of utero-sacral-ligaments and posterior-vaginal-fornix showed to be increased with gel (p<0.001). In 57 out of 80 patients the MRI has allowed us to diagnose deeply infiltrating endometriosis.Overall, the percentages of MRI-sensitivity, specificity, positive predictive value and negative predictive value were respectively 67.8%, 95.3%, 89.4 and 83.5% without gel, and 90.8%, 94.6%, 90.8% and 94.6% with gel; trans-vaginal ultrasonography sensitivity, specificity, positive predictive value and negative predictive value were 57.5%, 96.6%, 90.9% and 79.5%.In evaluation of utero-sacral-ligaments trans-vaginal ultrasonography, MRI without gel and with gel sensitivity was respectively 61.9%, 47.6% and 81%; for recto-vaginal-septum these values were 12.5%, 68.7% and 93.7%; for pouch of Douglas 82%, 87% and 97.4%; finally for posterior-vaginal-fornix 27.3%, 36.4% and 81.8%. ConclusionsMRI with gel opacification of vagina should be recommended for suspicion of deep infiltrating endometriosis, in particular for the added value in evaluation of recto-vaginal septum, utero-sacral ligaments and posterior vaginal fornix.

IMMUNOMAGNETIC REDUCTION FOR FETAL FIBRONECTIN DETECTION — A NOVEL METHOD TO DETECT THE PRETERM BIOMARKER

Preterm birth is the main cause of perinatal morbidity and mortality throughout the world. Fetal fibronectin (fFN) is one type of glycoprotein detected in the interface of the choriodecidual junction. Preterm labor is related to the disruption of the choriodecidual junction and thus fFN releases in the ectocervix or posterior vaginal fornix. Quantization of fFN can assist the diagnosis and prevention of preterm birth.In this work, we developed an immunoassay, the immunomagnetic reduction (IMR), to quantitatively detect fFN. It was found that the low detection limit for fFN via IMR is less than 10 ng/ml, which is much lower than clinic criteria 50 ng/ml. In addition to the high sensitivity, IMR assay shows such merits as low cost and high reliability for detecting fFN.

Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients

AimThe aim of this study is to prospectively evaluate 40 patients with a high rectovaginal fistula treated by a laparoscopic fistula division and closure, followed by an omentoplasty.Patients and methodsForty patients with a rectovaginal fistula, between the middle third of the rectum and the posterior vaginal fornix, resulting from different causes (IBD, iatrogenic and birth trauma) were treated by a laparoscopic excision of the fistula and insertion of an omentoplasty in the rectovaginal septum. The patients completed the gastrointestinal quality of life index questionnaire (GIQLI) and the Cleveland Clinic incontinence score (CCIS). All tests were performed at regular intervals after treatment.ResultsIn 38 (95%) patients with a median age of 53 years (range 33–72), the surgical procedure was feasible. In two patients, the fistula was closed without an omentoplasty, and a diverting stoma was performed. The median follow-up was 28 months (range 10–35). Two patients (5%) developed a recurrent fistula. In one patient, the interposed omentum became necrotic and was successfully treated laparoscopically. In another patient, an abscess developed, which needed drainage procedures. The mean CCIS was 9 (range 7–10) before treatment and 10 (range 7–13) after treatment (p = 0.5 Wilcoxon). The median GIQLI score was 85 (range 34–129) before treatment and 120 (range75–142) after treatment (p = 0.0001, Wilcoxon).ConclusionsLaparoscopic fistula excision combined with omentoplasty is a good treatment modality with a high healing rate for high rectovaginal fistulas and an acceptable complication rate.

Transvaginal natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopic adrenalectomy: first clinical experience

This study aimed to describe the initial clinical experience of transvaginal natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopic adrenalectomy (TNLA) and to evaluate its feasibility and efficacy. Between May and December 2010, 11 consecutive women were subjected to TNLA for adrenal tumors at the authors' center. With the patient under general anesthesia, a 5-mm trocar and a 10-mm trocar were inserted in the umbilical edge for conventional operating apparatus, and a 10-mm trocar was inserted in the posterior vaginal fornix for a conventional 30º laparoscope. Dissection was performed according to the method of a standard laparoscopic adrenalectomy. The adrenal gland, its tumor, or both were put into a homemade bag and then removed via the incision of the posterior vaginal fornix after complete resection. A total of 11 TNLAs were performed in this series. Only one conversion to open surgery was performed for one patient with Cushing disease, who was subjected to a splenectomy synchronously for an injury of the spleen. Except for this patient, no patients required a blood transfusion. The median operative time was 102 min (range 80-310 min), and the median estimated blood loss was 80 ml (range 30-800 ml). The median size of the mass in terms of the largest diameter was 4.7 cm (range 2.2-6.6 cm). There was no difference between pre- and postoperative median Female Sexual Function Index (FSFI) total scores (P = 0.102). All the patients except the one who had conversion to open surgery were very satisfied with the cosmetic result. The findings show TNLA to be a feasible and effective surgical technique that results in excellent cosmesis. It may be an alternative technique for the treatment of properly selected female patients with adrenal tumor.

Mixed urinary incontinence—time to uncouple urgency from stress?

"Mixed incontinence" is defined as a combination of stress and urge symptoms. Over time, it has morphed into a single entity, encompassing etiology and treatment. My perspectives are: (a) Stress incontinence (SI) and urge incontinence (UI) are different symptoms with often different anatomical causation and so should be treated separately; (b) It is illogical to group urgency with SI. Urgency may also be associated with frequency, nocturia, abnormal emptying and pelvic pain in patients with no SI ("posterior fornix syndrome"); and (c) There is growing evidence that urgency may be cured by surgical correction of a cystocele and/or apical prolapse in up to 80% of patients who do not have SI. In this anatomical context, sensory urgency, urge incontinence and urodynamic detrusor overactivity may all be hypothesized as different manifestations of a prematurely activated micturition reflex, caused by a lax vagina's inability to support bladder base stretch receptors. This statement can be tested with a simple clinical test, "simulated operations", whereby digitally supporting in turn the midurethra, bladder base and posterior vaginal fornix may cause a significant decrease in the urgency felt by the patient. The term "mixed incontinence" is only valid if both symptoms are caused by a lax pubourethral ligament. However, urgency may be caused by laxity in other parts of the vagina. Regarding stress and urge as separate entities will remove the confusion resulting from this definition, creating new directions for science and therapy.

Extragenital Müllerian adenosarcoma with pouch of Douglas location

BackgroundOf all female genital tract tumors, 1-3% are stromal malignancies. In 8-10% of cases, these are represented by Müllerian adenosarcoma an extremely rare tumor characterized by a stromal component of usually low-grade malignancy and by a benign glandular epithelial component. Variant that arises in the pouch of Douglas is scarcely mentioned in the medical literature.Case PresentationA 49-year-old para-0 woman, was seen at our OB/GYN-UNIT because she complained vaguely of pelvic pain. She had a mass of undefined nature in the pouch of Douglas. A simple excision of the mass showed low-grade Müllerian adenosarcoma with areas of stromal overgrowth. One and a half year after surgery, at another hospital, a mass was detected in the patient's posterior vaginal fornix and removed surgically. Six months later she came back to our observation with vaginal bleeding and mass in the vaginal fornix. We performed radical surgery. The pathological examination showed recurrent adenosarcoma. Surgical treatment was supplemented by radiation therapy.ConclusionsThe case of Müllerian adenosarcoma reported here is the third known so far in the literature that was located in the pouch of Douglas. To date, only two other such cases have been reported, including one resulting from neoplastic degeneration of an endometriotic cyst.

A double-blind randomized controlled trial of vaginal misoprostol for cervical priming before outpatient hysteroscopy

To evaluate the efficacy and safety of vaginal misoprostol for cervical priming before diagnostic outpatient hysteroscopy (OH) without anesthesia. Double-blind randomized controlled trial. University teaching hospital. One hundred fifty patients requiring diagnostic OH for investigation of infertility or abnormal uterine bleeding in the reproductive age. Patients were randomly allocated into two equal groups (n = 75). In group I, 200 μg misoprostol was inserted into the posterior vaginal fornix 3 hours before OH; in group II (control), vaginal examination was performed without misoprostol administration. A rigid 30° 4-mm hysteroscope was used in the vaginoscopic technique. Ease of cervical entry (Likert scale), procedural time, patient acceptability (Likert scale), and pain scoring (visual analog scale). Vaginal misoprostol significantly facilitated the procedure; cervical entry was easier, procedural time was shorter, patient acceptability was higher, and pain scoring was lower in group I compared with group II. Side effects of misoprostol were infrequent, minor, and transient. No complications were reported. The regimen of 200 μg vaginal misoprostol administered 3 hours before diagnostic OH is a simple, effective, and safe method of cervical priming to facilitate the procedure without anesthesia.

The Agony of Unsafe Abortion in A Teenager: A Case Report

This report represents a rare case of omental prolapse through posterior vaginal fornix laceration following an induced unsafe abortion. Miss T.R, a 14 year old orphan and junior secondary school 3 student had three different attempts at termination of 15 weeks pregnancy by a medical doctor in a private clinic. Physical examination at presentation in our teaching hospital revealed a very ill teenager, pale, febrile and tachycardic with an irregular fleshy mass protruding from the introitus and arising from a transverse laceration in the posterior vaginal fornix. After appropriate resuscitation, she had an emergency exploratory laparatomy with excision of the omentum , repair of posterior vaginal fornix laceration and manual vacuum aspiration of retained products of conception. The uterus and appendages were intact. The post operative period was uneventful with satisfactory wound healing. She was discharged home by the seventh day on admission after adequate counseling on contraception and referral to the family planning clinic.Key words: Unsafe abortion, Teenager, Omental protrusion, Laparotomy.

MISSED ABORTION

Objective: To compare the effectiveness of extra-amniotic cervical catheter and vaginal misoprostol as a cervical priming agent prior to surgical evacuation in first trimester missed abortions. Design: Randomized clinical trial. Setting: At lady Willingdon hospital gynecology unit 1 from 1st March 2008 to 28th February 2009. Methods: 100 patients with diagnosis of missed abortions of up to 12 weeks + 6 days were studied. The primigravida were included. They were divided in two groups. In group. A (50) patients 400 microgram (2 tablet ) misoprostol were placed high up in posterior vaginal fornix while in group B (50) patients extra-amniotic. Foleys catheter was placed aseptically 6 hour before surgical intervention as priming agent. Exclusion criteria: All multigravida, patients sensitive to prostaglandin, and with disturbed coagulation were excluded. Main Outcome Measures: The main out comes are 1, cervical dilatation and effacement 2,complications like fever, pain lower abdomen, headache and vomiting 3, amount of bleeding in ml after application of agent. Results: Cervical catheter proved to be good cervical priming agent comparable to misoprostol. Cervical dilatation was significantly better in misoprostol (&gt; 10 mm 44%, &gt; 8mm 30%, &gt; 5mm 20%) as compared to Foleys group (&gt;10 mm 24%, &gt; 8mm 38%, &gt; 5mm 20%) while in 3 (6%) dose of misoprostol was repeated and in 10 (20%) patient in Foleys group has no effect. The side effects occurred in both groups but systemic effects were more in misoprostol, pain lower abdomen 42% VS 46%, backache 18% VS 26%, fever 10% VS nil, headache 16% VS nil and no side effect 14% VS28%) as compared to Foleys catheter. Systemic effects were absent in Foleys catheter due to inert nature. Bleeding occurred in all patientswith misoprostol while it was absent in 48% cases in Foleys group (&gt;60ml 42% VS 8%, &lt;40ml 32% VS 14% &lt; 20ml 26% VS 30%). 48% cases had no bleeding in Foleys group. Conclusion: Cervical catheter proved to be good priming agent due to lesser systemic side effects as compared to misoprostol.

Incidence of Complications during Gynecologic Laparoscopic Surgery in Patients after Previous Laparotomy

Study Objective To estimate the incidence of complications arising during gynecologic laparoscopic surgery in patients who have undergone previous abdominal surgeries and to assess predictable factors associated with complications based on the characteristics of the previous laparotomy. Design Retrospective study (Canadian Task Force classification II–2). Setting University-affiliated hospital. Patients We enrolled 307 patients with a history of laparotomy who underwent laparoscopic surgery at our hospital between January 2002 and June 2009. Interventions The closed primary approach via either the ninth intercostal space or the posterior vaginal fornix was used to avert bowel injury. Complications were defined as organ injury that required repair during surgery and immediate conversion to laparotomy because of technical difficulties. Factors influencing complications during laparoscopic surgery were analyzed using logistic regression. Measurements and Main Results No complications developed during primary entry. Adhesiolysis was required in 195 areas of adhesion in 146 patients before laparoscopic surgery could proceed. These areas comprised 45 (14.7%) and 31 (10.1%) abdominal wall adhesions without and within the umbilicus, respectively, and 119 (38.8%) with intrapelvic adhesions. Complications in 41 patients (13.4%) included bowel damage (n = 35), urinary system damage (n = 4), and conversion to laparotomy because of technical difficulties (n = 2). Overall, 38 complications were laparoscopically repaired, and 1 complication was repaired at minilaparotomy. Intrapelvic adhesions were found in all patients with complications, and bowel adherent to the intrapelvis was identified in 38 of these (92.7%). The most significant predictive factors positively associated with development of complications according to logistic regression analysis were a history of abdominal myomectomy (odds ratio, 6.27; 95% confidence interval, 2.95–13.38; p <.001) and excisional endometriosis surgery (odds ratio, 5.80; 95% confidence interval, 2.08–16.13; p = .001). No patients developed severe delayed complications after surgery. Conclusion Our findings suggest that potential predictive factors of complications are a history of abdominal myomectomy and excisional endometriosis surgery performed because of intrapelvic adhesions.

The laparoscopic management of large ovarian cysts

To assess the laparoscopic management of large benign ovarian cysts as opposed to laparotomy. One hundred and thirty two women with ovarian cysts larger than 18 weeks pregnancy were managed laparoscopically. Five of these were borderline tumors. The cysts were aspirated laparoscopically and removed from the abdomen either by direct extraction, cutting into strips, electric morcellation or extraction through the posterior vaginal fornix. All the women were successfully treated and there were no complications. There were five borderline tumors and no frank malignancy. Follow up for 4 years revealed no malignancy. It is recommended that this is a satisfactory method of managing large benign cysts in carefully selected cases. However the exclusion of malignancy is mandatory.